Take Home Message: Athletic
trainers in different settings may adopt different strategies to assess and
manage concussions. Athletic trainers must continue to increase their use of
both objective concussion assessment tools and the standard clinical
examination to ensure the proper diagnosis and management of concussion.

It
is no surprise that athletic trainers have changed how they assess and manage concussions
over the years. With the introduction of numerous concussion assessment tools,
it is unknown how athletic trainers manage concussions and learn about new
concussion research. It is important to
learn this because it may help us develop strategies to improve quality of
care. The purpose of this study was to assess current clinical concussion
diagnostic and return-to-participation practices among athletic trainers. A
web-based survey was completed by 1053 certified athletic trainers (average
years of experience = ~ 11 years) working in a variety of settings. The survey
consisted of four different categories of questions. First, the authors
inquired about demographic information and number of concussions observed per
year. Second, the authors asked about tools or methods to diagnose, manage, and
safely return athletes to participation. Third, athletic trainers answered
questions regarding various widely used concussion-assessment tools and the
value of these tools. Finally, the last set of questions asked about the athletic
trainer’s understanding of current concussion literature and the effect of the
new information on their clinical practices. The data revealed that athletic
trainers saw an average of 10.7 concussions per year. Athletic trainers most
commonly reported using clinical evaluations to diagnose concussions. However,
it appears that most athletic trainers use a combination of various tools, such
as clinical evaluation, objective tools, and symptoms check-list. The authors
noticed several interesting trends between work settings when comparing survey
results. Collegiate athletic trainers used balance assessments and computerized
neurological testing more than athletic trainers in the high school settings. Furthermore,
athletic trainers in the clinical or high school setting relied on physician
return-to-play protocols and decisions, while athletic trainers in the
collegiate setting made these decisions themselves based on their assessments.
The majority of respondents was familiar with concussion publications and
directives and used these documents to make adjustments to their concussion
management.

The
results of this survey suggest that athletic trainers are continuing to make progress
when assessing concussions and formulating safe return-to-participation
decisions. However, this study shows
that there is still a large discrepancy in the methods clinicians use to
evaluate and manage concussions between settings. These differences could be
caused by the amount of funding or resources available to athletic trainers in
various settings. However, money should not dictate whether or not clinicians
have all the necessary concussion assessment and management tools. Safety is a
top priority of all athletic trainers and the most effective tools should be
provided in each setting to ensure the safety of every athlete. Clinicians should know that the most effective
concussion diagnostic and management tools are still unknown and that the use
of multiple tools may be the best current practice, including objective
measures and standard clinical examination. Finally, researchers should
continue to focus on concussion assessment tools and methods that allow the
clinician to make the best decision regarding the safety of the athlete. We can
assure proper and safe concussion assessment and management by staying updated
on the most recent literature and by conveying this evidence based medicine in
the educational setting.

Questions for
Discussion: As a clinician, what concussion assessment and management tools do
you use and why? What tools do you feel are the most effective in diagnosing
and return to play decisions?

10
comments:

Nic Philpot
said...

Being an athletic trainer at a high school, I feel like there should be a set return to play protocol for all concussions. My athletes must be symptom free for 24 hours, and return to baseline on the Impact test before they can start their return to play protocol, which is a minimum of 5 days. This is the county policy. The athletic trainer should make the return to play decision. This is because many high school athlete will go to a pediatrician when they are suspected of a concussion. In my experience, pediatricians are not up to date on concussion research, because it is not a daily focus of their practice. I often get notes that say that the athlete can return to play once they are symptom free. This leads the athlete to be more willing to say they are symptom free the next time they see the athletic trainer because they think they can practice that day. Another reason why I believe athletic trainers should manage the return to play is because we are the ones that see them on a daily basis. Physicians may see them once a week at the most.

This is a very interesting topic. I am currently writing a research paper on concussions. In the research that I have done I have found it was recommended that athletes must be symptom free for 24 hours before starting the 6 day return to play protocol. I also found that it was recommended that before an athlete starts aerobic activity they should complete cognitive activities. What is your opinion on this? Do you think that along with baseline assessments athletic trainers should have the athlete complete cognitive activities before returning to play?

I agree with Nic that the athletic trainer should make return to play (RTP) decisions. This practice is becoming more common in certain states. In Illinois, athletic trainers can now clear an athlete to RTP. The athletic trainers are specifically trained to manage concussions. The same can not be said about all physicians. The athletic trainers also have much more contact with the athletes than the physicians do. Using a combination of cognitive assessments and symptom scores prior to beginning a multi-step RTP protocol seems to be the best course of action.

I agree with Nic and Bethany that return to play decisions should be made by the athletic trainer. However, on top of that all athletic trainers need to have the specific tools that would allow them to safely and accurately return them to play. I believe that using baseline testing such as the impact test or the headminder CRI are great tools in monitoring the cognitive side of concussions, Not allowing the athlete to start their progression until they are back to their baseline score is one score the athlete cannot skew. An athlete can lie about being asymptomatic. However, they are not going to be able to lie during the neurological testing. Another essential tool is that the athletic trainer has a set return to play protocol that they follow. This way if during day 2 of the progression the athlete becomes symptomatic and the athletic trainer makes them wait a day before returning to the progression at day 1 there is documentation backing up their decision. Another main reason why athletic trainers should make the return to play decisions is that they know the athletes the best. Since they have day to day interaction with athlete they know the athletes demeanor. They would best be able to tell when they athlete is acting unlike themselves when they are concussed. At the same time they would also be the best to determine when the athletes demeanor is back to normal.

As an Athletic Training student we are taught to use multiple tools to help us diagnose a concussion. Although most teachers have their own opinions as which tools they think work best they basically use the same return to play format. Do you feel that using certain concussion tools in a certain order works better than another order? If you do why do you think that order works the best? Thank you

Hi Kaitlyn Johnson: Thanks for the comment. You might find the recent position statement from the American Academy of Pediatrics interesting. It states that " Students should be performing at their academic “baseline” before returning to sports, full physical activity, or other extracurricular activities following a concussion." http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.full.pdf+html

Kaitlyn Kelly: Previous research into other types of surveys and questionnaires have suggested that the order of questionnaires may be important. I think this could be the case with concussion tools but I haven't seen that evaluated yet. It's a very interesting question.

I completely agree with Nic and Bethany of the fact that athletic trainers should be the ones determining whether athletes are ready to return to play (RTP) after a concussion. As a current athletic trainer for a D1 university it is our policy that once they are symptom free and remain symptom free for a full 24 hours, they can begin to return to classes and must then complete a 6 day RTP protocol. We also use the computer based ImPACT test as a baseline for neurological testing and the BESS test as a baseline for balance. Therefore, I do believe that athletes should being progressing back to cognitive activity before physical activity. I do think that it would be interesting to evaluate the order on concussion questionnaires and RTP protocols to see which seems to work best. Many very interesting points were made so far in these comments. Thanks for the great discussion!

I find this study to be very interesting. At my clinical site we had guidelines on how to determine whether or not an athlete was safe to play again. The first day was light walking around the court or field, the next day was slight increase in intensity with a little bit of resistance. After that the athlete would sprint, following would be incorporating light lifts with resistance and finally the athlete has to complete one full practice. However, if at anytime during any one of these days, the athlete felt any symptoms they would stop immediately and start over in a few days. When the athlete could complete each day fully without any problems, they were good to play. Do you think that is a good way of determining whether or not neurocognitive function is back to normal?? Do you have any suggestions?

I work at a private boarding/day high school with grades 8-12. We follow the county concussion policy that the public schools in my county use although I have tweaked it to fit my school better. When an athlete is suspected of having a concussion they do have to go see their doctor but ultimately I as the ATC clear the athlete to return to sports. In some cases this year I have had to stick to my policy rather than follow what the doctor wrote in the athlete's note. In these cases it is important to have the support of your AD behind you for when parents call and want you to clear their child. At my school we also have academic accommodations that can be used in the classroom and that has been coordinated through the academic dean. In order for the athlete to return to full sports participation their IMPACT has to be back to baseline, they have to asymptomatic for 24hrs, they have to complete the RTP program and cannot be receiving any accommodation in the classroom. Typically this all happens within 10 days of initial injury.

Given the unique setting of a boarding school some students seek attention and use concussions as a way to get out of sports. They can fake symptoms and in some cases their IMPACT scores show deviation from baseline on multiple post-injury tests and scores are all over the place and not improving like they usually do. Does anyone else have this problem? Is there a way to determine if they are in fact faking? Needing to err on caution with this injury I feel stuck in the protocol with athletes who malinger or are just flat out faking.

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